Power Point Slide Catalogue From PreViser Corporation www.previser.com Risk-Based Treatment for Caries This slide series explains caries and the application of risk-based concepts for care.

Tooth Decay Defined An infection caused by bacteria commonly found in the mouth that destroys the tooth The bacteria are transmissible from parent or caregiver to child, child to child, and adult to adult The disease has many factors and many stages Courtesy PreViser Corporation, all rights reserved

Experimental Decay Development of enamel decay Decay arrested No oral hygiene Rinse 9x/day with 50% sucrose solution Regular oral hygiene Fluoride use Experimental caries in man. FR von der Fehr, H Loe, E Theilade. Caries Research 1970 volume 4 (2) pages 131 – 148. Enamel decay occurred in 21 days when patients did not practice oral hygiene and rinsed 9 times per day with a 50% sucrose solution. The decay was arrested in 30 days after regular oral hygiene resumed and fluoride was used. This provides proof that bacteria cause decay, sugar increases risk for decay and oral hygiene can prevent decay. 0 days 21 days 51 days Timeline Proof that: bacteria causes decay sugar increases risk oral hygiene can prevent decay von der Fehr et al 1970 Courtesy PreViser Corporation, all rights reserved

Stages of Decay The disease process begins with an infection, advances to demineralization, and ends with a cavity The process does not progress at a uniform rate but is cyclic and intermittent Demineralization occurs when decay-causing bacteria produce acids from food Courtesy PreViser Corporation, all rights reserved

Cyclic Process of Decay Demineralization Bacteria plus food makes the saliva very acidic within 5 minutes Remineralization Saliva becomes very acidic within 5 minutes of eating. The acid demineralizes the tooth. After 30 minutes the pH of saliva returns to normal. At this time the tooth remineralizes. The presence of fluoride during the remineralization results in fluor-apetite, which is more resistant to decalcification compared to the original tooth structure. Saliva is normal 30 minutes after eating Courtesy PreViser Corporation, all rights reserved

Tipping the Balance Remineralization Demineralization Cavity Infrequent or inadequate tooth cleaning Frequent meals and snacks Large amount of decay causing bacteria Deficient fluoride in saliva Caries results when the scale is tipped in favor of demineralization for a sufficiently long time period. The cavity is the irreversible outcome of the caries process. Once caries exists its repair by a restoration is indicated. Preventative treatment prevents demineralization or enhances remineralization. Neither process is visible using clinical techniques. The effectiveness of preventative treatment is not readily apparent, as this stage of the disease process is invisible. Prevention is immediately beneficial, as the disease process is always occurring and it is possible that some lesions that have nearly reached the irreversible visible stage would reverse and the tooth heal. The realization of its effectiveness cannot be immediately known since the processes are invisible. Courtesy PreViser Corporation, all rights reserved

Decay Progression O Backer Dirks, The clinical testing of agents for the prevention of dental caries. Adv Fluorine Res. 1966; 4: 1-2. Decay does not progress at a uniform rate. In fact over a period of 7 years only 13% of white spot lesions progressed to decay and 50% re-mineralized with the remaining 37% remaining unchanged. Progression of 72 white spot lesions followed for 7 years Backer-Dirks 1966 Courtesy PreViser Corporation, all rights reserved

Diagnosis of Decay Health Decalcification Decay Visual Normal tooth color White spot Black or brown Feel Hard Soft X-Ray Normal Black area Diagnostic techniques are insufficiently sensitive to accommodate all oral health needs. A condition of health is nearly indistinguishable from decalcification. By the time caries is evident prevention cannot be applied effectively and repair is needed. None of these methods can detect all lesions early enough to implement treatment to reverse the disease process Courtesy PreViser Corporation, all rights reserved

Occurrence of Symptoms 0 1 hour ? years 30 years Time line Heart Attack Anaphylactic Shock Toothache Disease processes that are chronic take a very long time to develop. Signs and symptoms for chronic disease processes occur late rather than early in the process. Prevention is preferable to waiting for the occurrence of disease. Common chronic disease processes include cardiovascular disease, cancer, periodontal disease, and caries. Each symptom occurs at the end of the colored bar Each disease process is invisible to diagnostic methods for most or all of the time within the colored bar Risk predicts chronic disease occurrence Courtesy PreViser Corporation, all rights reserved

Risk-Based Treatment Risk-based treatment prevents disease progression Disease State Cavity Risk-based treatment prevents disease progression Risk-based treatment prevents disease occurrence Decalcification Risk-based treatment prevents the occurrence of disease during the time it is invisible to diagnostic methods and it prevents disease progression for diagnosed lesions. Health Courtesy PreViser Corporation, all rights reserved

Prevention maintains a clinically healthy state Repair and Prevention Disease State Cavity Repair treats the consequences of disease, which may increase the risk of new disease Prevention maintains a clinically healthy state Decalcification Caries is irreversible and requires surgical removal of the lesion and restoration of the lost tooth structure. Prevention interrupts the disease process before the irreversible stage occurs to maintain a clinically health state. The repair of a tooth has little effect on reducing the risk of new caries lesions and may increase the risk. Restorations have little effect on the causes and risk factors for caries. Restorative margins may trap bacteria, restorations may weaken the tooth making it more susceptible to fracture, and trauma to the pulp may result in devitalization and an abscess. Health Courtesy PreViser Corporation, all rights reserved

Fillings Fillings have no measurable effect on decay-causing bacteria present on tooth surfaces Fillings have a finite life span and where each replacement filling leaves less tooth structure Fillings increase the risk of an abscess Fillings may increase the risk of tooth fracture and gum disease Fillings are more likely to increase a future adverse event than prevent one as fillings increase risk more than decrease it. Courtesy PreViser Corporation, all rights reserved

Prevention Preventive treatment can be effective at any time and age A diagnosis of decay could be indicative that additional lesions not yet visible exist Apparently healthy teeth might be in the early undetectable stages of decay Risk assessment can identify when risk is high and preventive treatment is beneficial Preventative treatment prevents an invisible entity from materializing. Since the disease process takes a variable amount of time during which the earliest stage is invisible and reversible it is logical that preventative treatment would be effective at any time during the invisible period and at any age. This was effectively shown by the work of Axelsson and colleagues. Furthermore, the effects of preventative treatment are immediate, although invisible. The effectiveness is revealed over time as disease incidence is reduced. Courtesy PreViser Corporation, all rights reserved

Tooth Decay Risk Tooth decay risk varies between individuals and over time coincident with a change in risk factors The highest decay-susceptible time is the first 2 years after tooth eruption, but can be high at any time Risk for caries is based on the risk factors for the individual. The highest decay-susceptible period is the first 2 years after tooth eruption. The decalcification-recalcification cycle especially with fluoride exposure can lessen caries incidence. Tipping the balance towards decalcification will result in caries. Effective preventative treatment requires that treatment is implemented based on the risk factors. Courtesy PreViser Corporation, all rights reserved

Supplemental and New Diagnostic Methods Plaque Formation Rate (PFRI) Salivary level of mutans streptococci (SM) New Diagnostic Methods Digital X-rays Fiber-optic transillumination (FOTI) Laser fluorescence (LF) Electrical conductance (EC) Ultrasound The plaque formation rate index (PFRI) has been described by Per Axelsson. Axelsson uses the plaque formation rate index with the salivary level of mutans streptococci to determine caries risk. Neither method is popular in the United States. New diagnostic methods are available. While these tools might detect disease in earlier stages none determine risk nor can they predict reversibility with preventative treatment. Earlier identification of lesions especially when this information is used to surgically repair the diseased site will always be inferior to preventing disease and reversing the disease process. Courtesy PreViser Corporation, all rights reserved

Plaque Formation Rate Score Description 1 1%-10% of surfaces 2 3 21%-30% of surfaces 4 31%-40% of surfaces 5 >40% of surfaces Amount of new plaque accumulated in 24 hours following tooth cleaning where patient refrains from oral hygiene Axelsson 1991 Courtesy PreViser Corporation, all rights reserved

Caries Risk Based on SM and PFRI SM/ml 1 2 3 4 5 Very Low Risk <0.5 mill Low Risk Moderate Risk 0.5-0.9 mill High Risk >0.9 mill SM/ml is Mutans streptococci measured in million per milliliter. PFRI is the plaque formation rate index. Axelsson 1991 Courtesy PreViser Corporation, all rights reserved

New Diagnostic Methods Very little clinical data are available to validate these technologies Goal is better accuracy over traditional methods to detect true cavities that should be filled Goal is detection of currently “invisible” lesions that are in a state of dynamic decalcification and recalcification Enhances risk assessment and application of preventive treatment Clarity of the diagnostic methods is required to distinguish which lesion will advance, remain unchanged, or heal. Diagnosis is a determination of the static or current disease state. Risk predicts the future disease state. Risk adds a dynamic dimension to health care. The best treatment practices require information about both diagnosis and risk. Courtesy PreViser Corporation, all rights reserved

Preventing Tooth Decay Reduction of decay-causing bacteria Health promoting dietary practices Exposure to fluoride Sealing susceptible tooth defects Proper frequency of dental visits This slide lists the common categories of treatment to prevent caries. Courtesy PreViser Corporation, all rights reserved

Reducing Decay-Causing Bacteria Personal teeth cleaning Twice daily tooth brushing and flossing or an equivalent aid for between the teeth Antibacterial rinses (chlorhexidene) Rinse with 10 ml for 1 minute at bedtime for 2 weeks repeating the cycle 2 months later Fluoride toothpaste Treat all family members Courtesy PreViser Corporation, all rights reserved

“Teeth Cleaned” Clarified All tooth surfaces including between teeth About half of all decay affects the tooth surfaces of adjacent teeth where a tooth brush and oral rinse does not reach The equivalent of not cleaning between teeth is washing the palm and back of your hands but not between your fingers Rinsing hands with water is not an effective alternative to scrubbing with soap Courtesy PreViser Corporation, all rights reserved

Dietary Practices Foods that are especially harmful contain sugars like sucrose, glucose, and fructose, cooked starch, and other carbohydrates Eat and drink no more than 3 meals and 3 snacks per day Sugar-free gum and mints, especially those that contain xylitol can be beneficial Courtesy PreViser Corporation, all rights reserved

Fluoride The incorporation of fluoride into developing enamel inhibits tooth decay, however its primary effectiveness occurs by its concentration in plaque and saliva to inhibit demineralization and enhance remineralization Fluoride inhibits plaque bacteria Courtesy PreViser Corporation, all rights reserved

Fluoride, cont. Fluoride is released from dental plaque during the acidic conditions of eating Released fluoride combines with calcium and phosphate to create a more decay-resistant enamel crystal structure Fluoride is available in water, toothpaste, over-the-counter rinses, prescription toothpaste and rinses, professional gels, foams, and varnishes Courtesy PreViser Corporation, all rights reserved

Fluoride, cont. Fluoridated toothpaste should be used twice daily Professional applications of fluoride is based on risk High-risk patients should have this done 2 to 3 times per year More fluoride is not necessarily better, especially for children younger than 6 years as fluorosis can affect cosmetically visible developing teeth Courtesy PreViser Corporation, all rights reserved

Tooth Sealants Plastic coating bonded to the biting surfaces of the back teeth Susceptible tooth defects should be sealed regardless of age Courtesy PreViser Corporation, all rights reserved

Frequency of Dental Visits Twice annual professional tooth cleaning as the sole method to prevent cavities is unlikely to be effective especially when risk is high Frequency of dental visits can be increased for closer monitoring of oral hygiene and dietary practices in addition to applying fluoride and sealants Courtesy PreViser Corporation, all rights reserved

Dealing with Objections Prevention doesn’t work Studies have shown that more than 90% of tooth decay can be prevented Prevention is only for the young Studies have shown that prevention works at any age The benefits of prevention take many years The benefits are immediate as prevention heals the invisible lesions Courtesy PreViser Corporation, all rights reserved

Objections, cont. It costs too much; My insurance doesn’t cover it Filling cavities costs more than preventing them Cavities can result in a root canal, cap, or extraction Dentures could ultimately cost more than “saving” your teeth Insurance doesn’t care if you have dentures Dentures are OK Dentures, especially lower ones, are not always successful, which then requires implants Courtesy PreViser Corporation, all rights reserved

Objections, cont. Flossing is too hard; no time to floss Tying shoelaces for a child is difficult but they learn the skill Flossing takes only a minute or two after the skill is learned Fillings prevent decay Fillings have no effect on decay-causing bacteria and hence do not reduce the risk of having more cavities Courtesy PreViser Corporation, all rights reserved